TheNursingWorkforce:Naviga4ngthroughTransforma4ve

HealthSystemChangeErinFraher,PhDMPP

ProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearch,UNC-CH

CenterforInterdisciplinaryHealthWorkforceStudiesWebinar

January20,2016

ThisworkisfundedbygrantsfromtheRobertWoodJohnsonFoundaHonandHRSA

Presenta4onOverview

•  Anursingshortage?Isthattherightques>on?•  Thecontext:newcaredeliveryandpaymentmodels

•  Oldschoolversusnewschoolapproachestoworkforceplanning

•  Howdowegettherefromhere?

•  Q&A

Areweaskingtherightques4ons?

•  The“shortagenarra>ve”—agrowing,agingpopula>onwithincreasedchronicdiseaseandexpandedhealthinsurancecoveragewilldemandmorecarethancanbeprovidedbynursingworkforce

•  Na>onalnursingmodelsmixed:somesuggestoverallsupplywilloutpacedemand,othersfindthatdemandwillexceedsupply

•  Isthereanursingshortage?That’sadifferentwebinar!•  Focusingonwhetherwehaveanursingshortagedistractsusfrom

amoreimportantques>on:

Willwehavetherightmixofnursesintherightloca4ons,special4esandprac4ceseOngswiththeskillsandcompetenciesneededtomeetthedemandsofatransformedhealthcaresystem?

Let1,000flowersbloom:ongoingexperimentsinhealthsystemtransforma4on

•  Growingnumberofpa>entcenteredmedicalhomes,accountablecareorganiza>onsandaccountablehealthcommuni>es

•  CMSac>velyfundingdemonstra>onprojects

•  SecretaryBurwellrecentlyannounced50%ofMedicarepayments>edtovalueby2018

Newmodelsofcare:keycharacteris4cs

•  Goal:providepa>entswithmorecomprehensive,accessible,coordinatedandhighqualitycareatlowercosts

•  Emphasisonprimary,preven>veand“upstream”socialdeterminantsofhealth

•  Careisintegratedbetween:–  medicalsub-special>es,homehealthagenciesandnursinghomes–  healthcaresystemandcommunity-basedsocialservices

•  EHRsusedtomonitorpa>entandpopula>onhealth—increaseduseofdataforrisk-stra>fica>onandhotspoang

•  Interven>onsfocusedatbothpa>ent-andpopula>on-level•  Paymentbasedonvalue,notvolume

Thereisintensefocusonpaymentandcaredeliverymodels,lessfocuson

workforcechangesneededtostaffnewmodels•  Weconductedliteraturesynthesison

workforceimplica>onsofnewmodelsofcare

•  FundedthroughHRSACoopera>veAgreementU81HP26495-01-00:HealthWorkforceResearchCenters

•  Collaborators:RachelMachta,BS,PhDstudentatUNC-CHandJacquelineHalladay,MDMPH,AssociateProfessorintheDepartmentofFamilyMedicineatUNC-CH

•  Ourfindingssuggestneedtoshihfrom“oldschool”to“newschool”workforceplanning

Reframe#1:Fromnumberstocontent

• Willwehaveenoughnurses?OldSchool

• Doesthenursingworkforcehavetheskillsandcompetenciesneededtofunc>oninnewmodelsofcare?

NewSchool

Howdonursesfitinnewmodelsofcare?

•  PCMHsandACOsemphasizecarecoordina>on,popula>onhealthmanagement,pa>enteduca>on,healthcoaching,dataanaly>cs,pa>entengagement,qualityimprovementetc.

•  Earlyevalua>onssuggestnewmodelsofcarenotshowingexpectedoutcomes

•  Couldbebecause:1.educa>onsystemnotadequatelypreparinggraduatestoprac>ceinnewmodelsofcareand/or2.exis>ngworkforcenotretooledwithnewskillsandcompetencies

•  Workerswiththerightskillsandtrainingareintegraltotheabilityofnewmodelsofcaretoconstraincostsandimprovecare(BodenheimerandBerry-Millel,2009)

Sources:BodenheimerT,Berry-MilleYR.Caremanagementofpa4entswithcomplexhealthcareneeds.Princeton,NJ:RobertWoodJohnsonFounda4on;2009.

Reframe#2:Fromprovidertypetoproviderrole

• Howmanyofx,y,zhealthprofessionaltypewillweneed?OldSchool

• Whatrolesareneededandhowcandifferentskillmixconfigura>onsmeetpa>ents’needsindifferentgeographiesandprac>ceseangs?

NewSchool

Manynewrolesemergingtoprovideenhancedcarefunc4ons

•  Maybefilledbyexis>ngstaffornewhires

•  It’scomplicated:–  Someroleshavesimilarfunc>onsbutdifferent>tles–  Otherroleshavedifferentfunc>onsbutsamename–  Dependingonseangandpa>entpopula>on,rolesareohenfilledbydifferenttypesofproviders

•  Twoofmostcommon:1. Rolesthatfocusoncoordina>ngcarewithinhealthcaresystem2. “Boundaryspanning”rolesthatcoordinatepa>entcarebetweenhealthcaresystemandcommunity-basedservices

Carecoordina4onwithinhealthcaresystemisbigandgeOngbigger

•  Increasedincen>vestokeeppa>entsoutofhospital

•  InJanuary2015,Medicarebeganpaying$42/monthformanagingcareforpa>entswithtwoormorechroniccondi>ons

•  Nursesmostohentakingonrolesascarecoordinators,casemanagersandtransi>onspecialists

•  Nursesincreasinglypartofteamwithpharmacists,socialworkers,die>ciansandothers

•  Mostofwhatweseethatistermed“carecoordina>on”ishappeningwithinthehealthcaresystem

Alsogrowingquickly:boundaryspanningrolesthatreachouttopa4entincommunity

PanelManagers HealthCoaches

Assumeresponsibilityforpa>entsbetweenvisits.UseEHRsandpa>entregistriesto

iden>fyandcontactpa>entswithunmetcareneeds.Ohen

medicalassistantsbutcanbenursesorotherstaff

Improvepa>entknowledgeaboutdiseaseormedica>onandpromotehealthybehaviors.Maybemedicalassistants,nurses,

healtheducators,socialworkers,communityhealthworkers,pharmacistsorotherstaff

•  Increasingnumberofstafffocusedonrolesthatshihfocusfromvisit-basedtopopula>on-basedstrategies

•  Twoexamples:

Reframe#3:Fromhealthworkforceplanningtoplanningforworkforceforhealth

• HealthworkforceplanningOldSchool

• PlanningforaworkforceforhealthNewSchool

Planningtosupportaworkforceforhealth,notahealthworkforce

Increasedboundaryspanningrolesrequire:•  Workforceplanningeffortsthatincludeworkerswho

typicallyprac>ceincommunityandhome-basedseangs

•  Embracingroleofsocialworkers,pa>entnavigators,communityhealthworkers,homehealthworkers,communityparamedics,die>ciansandothercommunity-serviceproviders

•  Weneedaworkforcefocusedonintegra>ngclinicalcarewithsocialservices

ThisistheaimofAccountableHealthCommuni4esModelannouncedbyCMS“Werecognizethatkeepingpeoplehealthyisaboutmorethanhappensinsideadoctor’soffice…wearetes>ngwhetherscreeningpa>entsforhealth-relatedsocialneedsandconnec>ngthemtolocalresourceslikehousingandtransporta>ontothedoctorwillul>matelyimprovetheirhealthandreducecoststotaxpayers…”SecretaryBurwell,hlp://www.hhs.gov/about/news/2016/01/05/first-ever-cms-innova>on-center-pilot-project-test-improving-pa>ents-health.html

AccountableHealthCommuni4esGoalsandAims

“ThefoundaHonofthemodelisuniversal,comprehensivescreeningforhealth-relatedsocial

needs—includinghousingneeds,foodinsecurity,uHlityneeds,interpersonalsafetyandtransportaHon

difficulHes—inallMedicareandMedicaidbeneficiarieswhoobtainhealthcareatparHcipaHngsites”

Alley,DE,AsomughaCN,ConwayPH,SanghaviDM.(2016).AccountableHealthCommuni>es—AssessingSocialNeedsthroughMedicareandMedicaid.NewEnglandJournalofMedicine.371;1:8-11.

Whataretheworkforceimplica4onsofthe“seamlesssocialwork”*model?

•  NEJMar>cleacknowledgeschallengein“developingaworkforcetodeliverinterven>onstovulnerablepopula>ons”

•  Whoistheworkforcethatwillassess,coordinateandnavigatepa>entneedsforclinicalandcommunity-basedservices?

•  Onceareferralismade,istheworkforceavailabletoprovidetheservice?

•  Dophysicians,socialworkers,nursesandotherhealthprofessionalshavetheskillstotakeonthese“bridgingroles”?

*New York Times, “Medicare to Test if Seamless Social Work can Improve Health”. Jan 5, 2016

Reframe#4:Fromfocusonpipelinetofocusonretoolingexis4ngworkforce

• RedesigningcurriculumfornursingstudentsinthepipelineOldSchool

• Retoolingthe2.9millionnursesalreadyemployedinUShealthcaresystemNewSchool

Workforcealreadyemployedinthesystemwillbetheonestotransformcare

•  Todate,mostworkforcepolicyfocushasbeenonredesigningeduca>onalcurriculumforstudentsinthepipeline

•  Butitisthe2.9millionnursesalreadyinthesystemwhowilltransformcare

•  Rapidhealthsystemchangerequiresnotonlyproducing“shinynewgraduates”butalsoupgradingskillsofexis>ngworkforce

•  Needtoiden>fyandcodifyemerginghealthprofessionalrolesandthenredesignpipelineandcon>nuingeduca>onprogramstotrainnursestotakeontheseroles

WorkforceisshidingfromacutetocommunityseOngs

•  Changesinpaymentpolicyandhealthsystemorganiza>on:–  Shihfromfee-for-servicetowardbundledcarepayments,risk-andvalue-basedmodels

–  Finesthatpenalizehospitalsforreadmissions

•  Willincreasinglyshihhealthcare—andthehealthcareworkforce—fromexpensiveinpa>entseangstoambulatory,communityandhome-basedseangs

•  Butwegenerallyeducatenursesininpa>entseangs

•  Currentworkforcenotadequatelypreparedtoworkinambulatoryseangsandpa>ents’homes

Exis4ngworkforcewillalsoneedmorecareerflexibility

•  Rapidandongoinghealthsystemchangewillrequireanursingworkforcewith“careerflexibility”

•  “Clinicianswantwell-definedcareerframeworksthatprovideflexibilitytochangerolesandseangs,developnewcapabili>esandaltertheirprofessionalfocusinresponsetothechanginghealthcareenvironment,theneedsofpa>entsandtheirownaspira>ons”(NHSEngland)

•  Needbelerandseamlesscareerladderstoallownursestoretrainfordeploymentindifferentseangs,servicesandpa>entpopula>ons

Retooling:Howdowegettherefromhere?

It’snotjustaboutretoolingtheworkforce.Weneedtoretoolthesystemthatsupportstheworkforce:educa>on,reimbursementandregula>onneedstobemoreresponsivetochangesinfront-linehealthcaredelivery

WeneedtobeYerconnecteduca4ontoprac4ce

“RevoluHonarychangesinthenatureandformofhealthcaredeliveryarereverberaHngbackwardinto…

educaHonasleadersofthenewpracHceorganizaHonsdemandthattheeducaHonalmissionberesponsivetotheirneedsforpracHHonerswhocanworkwithteamsinmoreflexibleand

changingorganizaHons…”

• Buteduca>onsystemislaggingbecauseitremainslargelyinsulatedfromcaredeliveryreform

• Needcloserlinkagesbetweenhealthcaredeliveryandeduca>onsystems—fouryear,twoyearandcon>nuingeduca>on

Source:RickeYsT,FraherE.Reconfiguringhealthworkforcepolicysothateduca4on,training,andactualdeliveryofcarearecloselyconnected.HealthAff(Millwood).2013Nov;32(11):1874-80.

Oneduca4onside:redesigncurriculumtopreparenursingworkforcefornewroles

•  Needtoredesigneduca>onsystemsonursescanflexiblygainnewskillsandcompetencies

•  Trainingmustbeconvenient–>ming,loca>on,andfinancialincen>vesmustbetakenintoconsidera>on

•  Needtopreparefacultytoteachnewrolesandfunc>ons

•  Clinicalrota>onsneedtoinclude“purposefulexposure”tohigh-performingteams

Source:Laddenetal.TheEmergingPrimaryCareWorkforce.PreliminaryObserva4onsfromthePrimaryCareTeam:LearningfromEffec4veAmbulatoryPrac4cesProject”.AcademicMedicine;1013,88(12):1830-1835.

Onprac4ceside:redesignhumanresourceinfrastructuretosupportnewroles

•  Needtominimizeroleconfusionbyclearlydefiningandtrainingfornewfunc>ons

•  Jobdescrip>onshavetoberewrilenorcreated

•  Workflowshavetoberedesigned

•  Lackofstandardizedtrainingandfundstosupporttrainingisbigobstacle

•  Exis>ngstaffwon’tdelegateorsharerolesifdon’ttrustotherstaffmembersarecompetent

•  Timespenttrainingisnotspentonbillableservices

Regulatorysystemneedstoberestructured

“TheworkforceinnovaHonsneededtoimplementACAprogramsrequireanadaptableregulatorysystemcapableofevolvingwiththehealthcareenvironment.ThehealthprofessionregulaHonsysteminplacetoday

doesnothavetheflexibilitytosupportchange.”

Tocreateamoredynamicregulatorysystem,weneed:• todevelopevidencetosupportregulatorychanges,especiallyfornewroles• belerevalua>onofpilotworkforceinterven>onstounderstandifinterven>onsimprovehealth,lowercostsandenhancesa>sfac>on• toestablishana>onalclearinghousetoprovideup-to-dateandreliableinforma>onaboutscopeofprac>cechangesinotherstates

Source:DowerC,MooreJ,LangelierM.Itis4metorestructurehealthprofessionsscope-of-prac4ceregula4onstoremovebarrierstocare.HealthAff(Millwood).2013Nov;32(11)

Whoisgoingtopayforallthisretoolingweneedtodo?

•  Adequateandsustainablepaymentmodelstoretoolandredeploytheworkforcearelacking

•  Manyworkforceinnova>onsaresupportedbyone->mefunds.Ifpaymentmodelsdon’tchangerapidlyenough,willtheseinterven>onsbesustainable?

•  1,000flowersarebloomingbutareadequatedollarsavailabletoconductresearchandevalua>onsnecessarytodevelopevidencebaseneededtosupportworkforceredesign?

Addi4onalResources

Seeourpaper,“BuildingaValue-BasedWorkforce,”onourwebsite

FundedbyHRSAthroughtheCarolinaHealthWorkforceResearchCenter

hlp://www.shepscenter.unc.edu/programs-projects/workforce/projects/carolina-health-workforce-research-center/

AndourRWJ-fundedbrief:NursinginaTransformedHealthCareSystem:NewRoles,NewRules

Cita>on:FraherE,SpetzJ,NaylorM.NursinginaTransformedHealthCareSystem:NewRoles,NewRules.LDI/INQRIResearchBrief.June2015.hlp://ldi.upenn.edu/uploads/media_items/inqri-ldi-brief-nursing.original.pdf.

“Whatwillittaketoop1mizecontribu1onsofnurses?• Redesignthenursingcurriculumtoeducatenurseswithnewcompetencies;• RetrainexisHngnurseswithnewskillsandknowledge;• RevamplicensingexaminaHonandrequirementstoreflectthenewcurriculum;and• Restructurethestateregulatorysystemtoallowflexibledeploymentofthenurseworkforce.”

hlp://ldi.upenn.edu/uploads/media_items/inqri-ldi-brief-nursing.original.pdf-QuotedfromJanetWeiner,MPH.PennLDIVoicesBlog.“Re:Nurses”.

June25,2015.hbp://ldi.upenn.edu/voices/2015/06/25/re-nurses

Contactinfo

ErinFraher,PhD

Director

ProgramonHealthWorkforcePolicyandResearch

erin_fraher@unc.edu

919-966-5012

hlp://www.healthworkforce.unc.edu